Facilitated Transitions From Postpartum to Primary Care Coordination for People With Chronic Conditions

Launched by MASSACHUSETTS GENERAL HOSPITAL · Aug 13, 2024

Keywords

ClinConnect Summary

This clinical trial is focused on improving the way new mothers with chronic health conditions, such as high blood pressure, diabetes, anxiety, and obesity, receive care after giving birth. Many new mothers struggle to connect with their primary care doctors, which can make managing their health more difficult. The study is testing a new approach to help these mothers transition from hospital care to regular doctor visits more smoothly, using supportive methods based on understanding how people make decisions about their health. By doing this, the researchers hope to encourage ongoing medical care that helps mothers stay healthy for themselves and their families.

To be eligible for the trial, participants need to be at least 18 years old, and they should be receiving care at a specific hospital practice. They must be pregnant or have recently given birth to a healthy baby and have one or more of the targeted chronic conditions, like diabetes or high blood pressure. Participants will have access to their medical records online and will be involved in regular check-ins for feedback throughout the study. This trial is not yet recruiting participants, but it aims to set a new standard for postpartum care that could benefit many women in the future.

Gender

FEMALE

Eligibility criteria

• • Inclusion Criteria
• • Receiving obstetric care at an MGH-affiliated obstetrics practice (except for the MGH HOPE Clinic, which has a unique care model that provides prenatal and postnatal care for individuals with substance use disorder, including the provision of primary care through 2+ years postpartum)
• • Pregnant with a live fetus or delivered a live-born neonate ≥24 weeks of gestation, based on the clinical estimate of gestational age
• • If postpartum, has a neonate that is currently living at the time of enrollment
• * Has one or more of the following conditions listed in the "Problem List," "Medical History," or clinical notes during prenatal, intrapartum, or postpartum encounters in the EHR (or in the case of BMI, the patient's anthropometric measurements):
• • Chronic or essential hypertension
• • Hypertensive disorders related to pregnancy (e.g., pre-eclampsia)
• • Type 1 or 2 diabetes (i.e., pre-existing diabetes)
• • Gestational diabetes
• • Class II Obesity (pre-pregnancy body mass index ≥35 kg/m2; or if pre-pregnancy body mass index is not known, a first trimester BMI of ≥35 kg/m2)
• • Depression or anxiety disorder
• • Has a primary care clinician listed in the patient's medical record
• • Has access to or agrees to be enrolled in the electronic health record patient portal and consents to be contacted via these modalities
• • Able to read/speak English or Spanish language
• • Is age ≥18 years old
• • Exclusion Criteria
• • • Any individual not meeting all inclusion criteria